Despite the close attention paid to medication adherence by healthcare providers, pharmaceutical marketers and manufacturers, and health educators, it continues to be an enormous problem with both financial and physical consequences. In one recent meta-analysis of medication adherence studies, the average adherence rate across conditions was just 60 percent.1
The New England Healthcare Institute estimated an annual $290 billion in avoidable direct and indirect costs associated with medication non-adherence.2 These costs include additional inpatient and outpatient care as well as patient disability and death.
Healthcare system stakeholders can use behavioral science to expand their toolkits and enhance the efficacy of their communication in improving medication adherence. The behavioral science behind the digital health coaching can be distilled into seven guidelines for creating compelling adherence messaging at each stage of the patient's experience with medication. Each guideline aligns with key milestones along the patient's experience with medication, from the initial prescription, to first fill, to ongoing adherence. The guidelines can help with decisions about which audience to target, what message to send, and what vehicle to use. By keeping these guidelines in mind when reaching out to target audiences, it can help improve the odds of helping them change their medication-related behaviors for the better.
Guideline 1: Explain the condition and role medication plays in treatment. This guideline is particularly critical when a person is first prescribed a medication. Building a mutual understanding of the benefits provided by the medication helps the patient create a rationale for the proper use of medication. This is also an opportunity to help the patient understand his or her condition and how lifestyle changes might work in concert with medication to support a better quality of life. Education about possible medication side effects — and, particularly, expected duration and appropriate coping mechanisms — may help the patient develop a plan to remain adherent through any rough spots. This sort of planning has been shown to help people sustain a desired behavior through difficulty3 and may be particularly critical for patients beginning a medication that has side effects. Finally, establishing an understanding that adherence can be difficult and the patient may encounter barriers opens the potential for a dialogue around these issues down the road.
Guideline 2: Build an effective therapeutic relationship between patients and providers. In a survey of patients taking medication, the most satisfied ones reported that their physicians' style of working with them matched their own preferences for collaboration. Patients were especially satisfied when they sought collaboration from their provider and received it.4 Encouraging patients to engage in open dialogue with their providers around medication can help achieve the first guideline while also fostering a trusting relationship that supports adherence over time. Providers should consider asking their patients what type of relationship they would find most satisfying; if they favor more collaboration, soliciting their feedback will be particularly important to a strong relationship. Patient outreach could even provide a toolkit to help patients work effectively with providers, in the form of sample questions to ask, coaching on communication techniques or key concerns to discuss.
Guideline 3: Identify the pros and cons of starting and staying on medication. This guideline is useful for patients on the verge of the first fill. Once someone is convinced of the benefits of medication and decides to fill the prescription, a "pro-con" list can help provide lasting motivation and prepare the patient for therapeutic difficulties. For example, a "pro" might remind the patient that taking medication reduces impairment, while a "con" might be a medication's side effects — which could prompt a conversation with the healthcare provider about coping strategies. Rhetorical questioning is a useful tool to coach the patient to create a meaningful pro/con list and arrive at a reasoned decision to fill the prescription as recommended by the provider.
Guideline 4: Provide motivation and build patient confidence. For most people, taking medication is a conscious decision. Making that decision requires some motivation. As mentioned previously, some of the "pros" of treatment touch on motivation, such as reducing impairment from a condition, enabling increased participation in daily life, increasing energy or enhancing quality of life. Most people are not motivated to be healthy for health's sake, but rather in order to enable other achievements or enjoyments in life. Adherence communications can orient patients to these sorts of benefits.
On a more granular level, people can be motivated to continue with a process if their self-efficacy is supported along the way. Medication adherence can be difficult at first, but by emphasizing small wins and outlining a plan for success, patients can create strong self-efficacy. Trackers, reminders and pillboxes may have limited value once a patient has developed an adherence habit, but at the initiation of therapy, these tools can create a solid foundation to help sustain the new behavior. At the same time, barriers to adherence are real and should not be minimized. Rather, help support patient self-efficacy by acknowledging barriers and encouraging solution-oriented thinking about them.
Guideline 5: Demonstrate how to build a healthy new habit. While there may be complexities to the decision to take medication, the actual mechanics of it often boil down to habit. The most common barriers to adherence reported by users of digital health coaching are related to habit and routine5 — for example, being forgetful while traveling or having difficulty coordinating multiple medications. Pragmatic information about how to structure a routine that includes medications can benefit people who struggle with this common issue. As the previous guideline suggests, tools that help remind patients to take medication on a schedule can be helpful, particularly when a prescription is new. Similarly helpful is any sort of communication or tip that helps create a cue to action. The target patient segment may also have additional barriers that relate to habit formation. For example, people who travel frequently or have unpredictable daily schedules are especially likely to struggle with routine, and may respond well to strategies to combat inconsistency.
Guideline 6: Acknowledge that health is emotional, and encourage coping strategies. For people who have received the diagnosis of a chronic condition, medication may serve as an ongoing reminder of loss and mortality. Whether a person has hypertension or cancer, it is not uncommon to feel anger, anxiety, or grief in response to the diagnosis. Over time, as the patient's initial reaction to the diagnosis fades, these emotions may rise to the forefront and pose barriers to adherence. Acknowledging the emotional toll of a health condition both creates rapport with patients and helps to normalize a difficult experience. When having a face-to-face patient encounter, take the opportunity to ask about the patient's emotional response to the illness. Marketing communications also offer an opportunity to address difficult feelings through emotional modeling — for example, highlight people who have experienced a difficult health situation, perhaps struggled with an emotional response, and have shown positive coping over time. The most essential aspect of this guideline is not to minimize the patient's emotional reaction to illness or medication; even if these reactions seem irrational, they are a real and important part of the patient experience.
Guideline 7: Show how environmental factors can impact health decisions. Not all aspects of a person's behavior come from a purely internal place. The environment influences behavior and attitudes in ways both subtle and dramatic. Consider how cultural norms might affect a person's willingness to speak with a practitioner about certain health problems or to take medication for them. Stigma is another environmental factor that may influence adherence; someone who feels shame and an excessive need for privacy around their illness is less likely to ask for help staying adherent. To the extent that using communications to raise awareness around these cultural issues — thereby enabling patients to react to them consciously rather than being unknowingly influenced — could enable improved adherence.
Health literacy, too, is a way the environment shapes patients and the way they interact with the healthcare system. Many people who take medication have low health literacy and may not easily be able to make sense of instructions and packaging.6 Even people with higher levels of health literacy may be stymied by complicated routines that involve multiple medications taken at multiple times of day, each with different instructions and side effect profiles. The healthcare provider and the marketer are in two unique positions to provide clearly stated, actionable information that helps patients take medications appropriately.
So the challenge for you is: How can you create messaging around adherence that is easy to understand and fits within your patients’ environment? If you're targeting a culture that distrusts physicians, how can you leverage more trusted resources such as pharmacists or community leaders or work to improve trust? If your messages concern a stigmatized condition, how can you normalize it or provide an opportunity for people to address it privately?
Conclusion
Although these guidelines are based in science, incorporating them into communications is certainly an art. By keeping the guidelines front-of-mind as part of the creative challenge, and as both development and evaluation tools, can help build communications that are compelling and effective.
Most communication efforts will draw on just one or two of the guidelines in order to deliver a clear and compelling message. Which guidelines are appropriate to use will vary depending on the target audience, their placement in the patient journey, the communication vehicle being used and any goals of the communication beyond adherence promotion. In fact, trying to include all seven guidelines in a single conversation or communication piece, particularly a shorter piece such as a direct-to-consumer advertisement for magazine placement (or a brief conversation during a provider office visit), may create a cluttered and unfocused message. Think strategically about which guidelines make the most sense for the patient.
Most importantly, however, is to always keep the intended audience — the patient — at the forefront of the communication development process. Ground communication in empathy, so that your recipients will see the interest invested is not just marketing a product or a service, but also helping make healthy changes in the world.
Amy Bucher, PhD, is associate director of behavioral science at Wellness & Prevention, a Johnson & Johnson company. Her work focuses on how to motivate health behavior change through individual and environmental interventions.
Elizabeth Inglis currently serves as clinical engagement specialist and content development lead at SocialWellth. She has 11 years of experience in health promotion, program design and risk consulting, and earned her MPH in Health Behavior and Health Education from the University of Michigan.
1 Demonceau, J., et al. (2013). Identification and assessment of adherence-enhancing interventions in studies assessing medication adherence through electronically compiled drug dosing histories: A systematic literature review and meta-analysis. Drugs, 73(6), 545-562. DOI: 10.1007/s40265-013-0041-3
2 New England Healthcare Institute (2009). Thinking outside the pillbox: A system-wide approach to improving patient medication adherence for chronic disease. A NEHI Research Brief. Retrieved May 21, 2013 from www.nehi.net/uploads/full_report/pa_issue_brief__final.pdf.
3 Webb, T. L., & Sheeran, P. (2003). Can implementation intentions help to overcome ego depletion? Journal of Experimental Social Psychology, 39(3), 279-286. Doi: 10.1016/S0022-1031(02)00527-9
4 Wellness & Prevention Book of Business Data, Care For Your Health Program Submissions from program launch to 3/31/2013, n=6,456.
5 Wellness & Prevention Book of Business data, Care for your Health program submissions from launch to May 21, 2013, N = 71,162
Gazmararian, J. A., Kripalani, S., Miller, M. J., Echt, K. V., Ren, J., & Rask, K. (2006). Factors associated with medication refill adherence in cardiovascular-related diseases: A focus on health literacy.
6 Journal of General Internal Medicine, 21(12), 1215-1221. Doi: 10.1111/j.1525-1497.2006.00591.x
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